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Effective Date:
11/2019Documents
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Document
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Document
Instructions
Updated: 11/2019
Purpose
Form 3048 is completed to notify applicants if they are eligible for the Title V Fee-for-Service Program, Primary Health Care Services Program or Epilepsy Program benefits.
Form 3048 is also completed to notify clients of the Title V Fee-for-Service Program, Primary Health Care Services Program or Epilepsy Program benefits to report changes in their situation and their liability if they fail to report changes.
When to Prepare
Complete the form for individuals applying for the Title V Fee-for Service Program, Primary Health Care Services Program or Epilepsy Program benefits.
Number of Copies
Complete an original and one copy.
Transmittal
Give the original form face-to-face or mail the form to the individual applying for assistance. File a copy in the case record.
Form Retention
Keep the case record copy for three state fiscal years after eligibility begins. However, eligibility is valid for a maximum of 12 months.
Detailed Instructions
Complete the information listed on the form.